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Date run 1115/2015 10:57:29Ai SAN JO,, IIN COUNTY ENVIRONMENTAL HEAL * DEPARTMENT Repot#5027 <br /> Run by <br /> Facility Information as of 1/15/2015 Pagel <br /> Record Selection Criteria: Facility ID FA0022744 <br /> Make changeslcorrections in RED ink.. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN/Fed Tax ID <br /> Owner ID OW0020534 New Owner ID <br /> Owner Name Golden State Supply LLC <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 919-573-3000 <br /> Mailing Address PO Box 26006 <br /> Raleigh, NC 27611 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022744 10419802 <br /> Facility Name CQ of Lodi#7014 <br /> Location 730 S Beckman Rd Ste C <br /> Lodi, CA 95240 <br /> Phone 209-369-4395 x <br /> Mailing Address PO Box 26006 <br /> Raleigh, NC 27611 <br /> Care of CARQUEST Auto Parts#7014 <br /> Location Code Alt Phone <br /> BOS District Fax <br /> AP'N Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0041685 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility I Account <br /> Account Name Elizabeth Dillon (Circle One) <br /> Account Balance as of 1/15/2015: $0.00 <br /> (Circle One) <br /> Transfer to Adiveilnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0539758 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0539757 EE0001422-ARIS VELOSO Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSIEHD hourly charges associated with this facility <br /> Or activity will be billed to the party identified as the OWNER on this farm. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State andlar <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 I <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: _ Amount Paid Date 1 1 <br /> Payment Type Check Number Received by _ <br /> RENS: Date�1 I l Account out: U6 Date /,2- r <br /> COMMENTS, <br /> C N�t/�J Ac_..k,.T-il -4- ��Lot�R-cil v ilra Ck-Yl-S <br />